Catheter insertion system and method of fabrication

ABSTRACT

A robotic instrument driver for elongate members includes a first carriage positionable on a bed and beside a patient access site for manipulating a first elongate member, and a second carriage positionable proximate the bed, the second carriage configured to articulate the first elongate member, wherein the second carriage is movable independent from the first carriage.

BACKGROUND

Robotic interventional systems and devices are well suited for performing minimally invasive medical procedures as opposed to conventional techniques wherein a patient's body cavity is open to permit a surgeon's hands to have access to internal organs. Advances in technology have led to significant changes in the field of medical surgery such that less invasive surgical procedures, in particular, minimally invasive surgery (MIS), are increasingly popular.

MIS is generally defined as surgery performed by entering the body through the skin, a body cavity, or an anatomical opening utilizing small incisions rather than large, open incisions in the body. With MIS, it is possible to achieve less operative trauma for the patient, reduced hospitalization time, less pain and scarring, reduced incidence of complications related to surgical trauma, lower costs, and a speedier recovery.

MIS apparatus and techniques have advanced to the point where an elongated catheter instrument is controllable by selectively operating tensioning control elements within the catheter instrument. At least two types of catheters may be employed for surgical procedures. One type includes an electrophysiology (EP) catheter typically uses a navigating distance of 15 cm or less. EP catheters also may be relatively thick and stiff and thus, due their short length and high stiffness, EP catheters typically do not suffer from a tendency to buckle during use.

In comparison to EP procedures, vascular procedures include a greater amount of catheter insertion length, a greater number of catheter articulation degrees of freedom (DOFs), and a mechanism for manipulation of a guide wire. For that reason, a bedside system provides mounting for splayer actuation hardware configured to provide the catheter insertion lengths, mounting which accounts for an increase in splayer size due to added DOFs, and mounting for a guide wire manipulator. Thus, vascular catheters typically include a relatively long stroke, such as one meter or more. Relative to EP catheters, vascular catheters are typically smaller, thinner, and more flexible, and therefore have a greater tendency to buckle than EP catheters. As such, it is typically desirable to feed vascular catheters into the patient with minimal bending to reduce the tendency to buckle. Known vascular robotic catheter systems are therefore typically suspended over the patient that is lying prone on a bed.

A vascular catheter system typically includes elongate members that include an outer catheter (sheath), an inner catheter (leader), and a guidewire. Each is separately controllable and therefore they can telescope with respect to one another. For instance, a sheath carriage controls operation of the sheath and is moveable in a generally axial motion along the patient, and a leader carriage controls operation of the guidewire and is likewise moveable in the generally axial direction of the patient. Typically, the leader carriage and the sheath carriage are positioned on a remote catheter manipulator (RCM), which is supported by a setup joint (SUJ). The SUJ is typically positioned on a rail that is itself mounted to the bed, below which the patient is positioned.

As such, the RCM typically carries the weight of both carriages as well as the other hardware that are used to operate the system. And, to provide the full stroke, the SUJ is passed through the full range of motion which, as stated, can exceed one meter. To do so, typically the SUJ is moved or rotated with respect to the rail and the rail is stationary. For this reason, a bedside system is typically included that provides mounting for splayer actuation hardware configured to provide catheter insertion lengths, and mounting for a guide wire manipulator. Because this hardware is mounted on the rail, the system can not only be cumbersome to work with, but it can interfere with other system operation (such as the C-arm and monitors), as well as provide significant weight that is carried by the bed.

Thus, there is a need to for an improved catheter system that operates over a smaller footprint, weighs less, and does not compromise the propensity for the catheter to buckle.

SUMMARY

A robotic instrument driver for elongate members includes a first carriage positionable on a bed and beside a patient access site for manipulating a first elongate member, and a second carriage positionable proximate the bed, the second carriage configured to articulate the first elongate member, wherein the second carriage is movable independent from the first carriage.

A catheter surgical system coupled to a bed configured to support a patient during surgery, the system includes a first carriage configured to couple to the bed and to manipulate a first elongate member, and a second carriage configured to couple to the bed adjacent to where the patient is positioned during surgery, wherein the second carriage is configured to articulate the first elongate member, and the second carriage is moveable autonomously from the first carriage.

A method of assembling a catheter insertion system includes providing a first carriage that is positionable proximate a patient surgical support structure, the first carriage configured to manipulate an elongate member into a patient, and providing a second carriage that is positionable proximate the patient surgical support structure and beside a patient on the patient surgical support structure, wherein the second carriage is configured to articulate the first elongate member and is moveable independently from the first carriage.

BRIEF DESCRIPTION OF THE DRAWINGS

While the claims are not limited to a specific illustration, an appreciation of the various aspects is best gained through a discussion of various examples thereof. Referring now to the drawings, exemplary illustrations are shown in detail. Although the drawings represent the illustrations, the drawings are not necessarily to scale and certain features may be exaggerated to better illustrate and explain an innovative aspect of an example. Further, the exemplary illustrations described herein are not intended to be exhaustive or otherwise limiting or restricted to the precise form and configuration shown in the drawings and disclosed in the following detailed description. Exemplary illustrations are described in detail by referring to the drawings as follows:

FIG. 1 is a perspective view of an illustration of a robotically controlled surgical system, according to one exemplary illustration;

FIG. 2 illustrates a plan view of the system of FIG. 1; and

FIGS. 3 and 4 illustrate exemplary components of the catheter insertion of FIGS. 1 and 2.

DETAILED DESCRIPTION

Referring to FIGS. 1 and 2, a robotically controlled surgical system 100 is illustrated in which an apparatus, a system, and/or method may be implemented according to various exemplary illustrations. System 100 includes a robotic instrument driver or catheter insertion system 102 having a robotic or first or outer steerable complement, otherwise referred to as a sheath instrument or sheath carriage 104 and an inner steerable component or otherwise referred to as a leader carriage 106 on a base 108.

During use, a patient is positioned on an operating table or surgical bed 110 (generally referred to as “operating table”) to which sheath carriage 104 and leader carriage 106 are coupled or mounted. In the illustrated example, system 100 includes an operator workstation 112, an electronics rack 114 and an associated bedside electronics box (not shown). Surgical bed 110 is positioned on a base or support 116. A surgeon is seated at operator workstation 112 and can monitor the surgical procedure, patient vitals, and control one or more catheter devices.

System components may be coupled together via a plurality of cables or other suitable connectors 118 to provide for data communication, or one or more components may be equipped with wireless communication components to reduce or eliminate cables 118. Communication between components may also be implemented over a network or over the internet. In this manner, a surgeon or other operator may control a surgical instrument while being located away from or remotely from radiation sources, thereby decreasing radiation exposure. Because of the option for wireless or networked operation, the surgeon may even be located remotely from the patient in a different room or building.

FIG. 2 is a plan view of system 100 of FIG. 1 (with workstation 112 and electronics rack 114 omitted). As seen in FIGS. 1 and 2, robotic instrument driver 102 includes a rail 120 on which sheath carriage 104 and leader carriage 106 are positioned and to which they are coupled. Both carriages 104, 106 are positioned proximate bed 110 and in one embodiment are positioned on rail 120, which itself is positioned on and attached to bed 110. Rail 120, in the illustrated embodiment, is positioned beside the patient. That is, rail 120 is positioned proximate a location on the bed where the patient lies during a surgical procedure.

An elongate member 122 that may include an inner catheter and/or guidewire extends between sheath carriage 104 and leader carriage 106, and generally along a length direction 124 for bed 110. Carriages 104, 106 are also each moveable along rail 120 and along direction 124, which in one embodiment is defined also as an advancement axis for elongate elements of the catheter. According to one embodiment, direction 124 also corresponds to a longitudinal axis of bed 120, which generally corresponds to a length direction of the patient. However, it is contemplated that carriages 104, 106 may also be positioned with respect to one another and at an angular orientation with respect to the longitudinal axis of the patient positioned on bed 110. That is, in one embodiment (not shown) rail 120 is positioned at an angle (other than zero degrees) with respect to the longitudinal axis of the patient to better angle components of the catheter with respect to the patient. Leader carriage 106 is configured to advance or retract elongate member 122 when leader carriage 106 is moved along a guidewire axis 126 that is defined as an axis between sheath carriage 104 and leader carriage 106. Each carriage 104, 106 is positionable proximate bed 110 and positionable beside a patient on bed 110, and also repositionable during surgery. Carriage 104, 106 are each moveable independently or autonomously from one another.

Sheath carriage 104 is rotatable about a sheath carriage rotation axis 128. Axis 128 is, in the illustrated embodiment, generally and approximately orthogonal to guidewire axis 126, and also generally orthogonal to direction 124. In such fashion, a sheath 130 is extendable (for instance, during surgery) from sheath carriage 104 and is also directable to optimize an approach angle of elongate element(s) 130 with respect to the patient and to an access site 132 which, in the illustrated instance, is proximate a groin of the patient. Thus sheath 130 and other elongate members extending therefrom may be controllably rotated (or angled) with respect to the patient.

Further, it is contemplated that a sterile drape is positionable on system 100. That is, a sterile drape (not shown) may be positioned between the patient and between catheter assembly 102 such that components of catheter assembly 102 (i.e., carriages 104, 106) are isolated from the patient.

FIG. 3 illustrates components of the robotic instrument driver of FIGS. 1 and 2. As discussed, robotic instrument driver 102 includes sheath carriage 104 and leader carriage 106 positioned on rail 120. Each carriage 104, 106 is moveable 300 axially with respect to the other, as well as with respect to rail 120. Elongate member 122 extends between carriages 104, 106 and passes through carriage 104 within sheath 130. More generally, catheter or elongate member(s) 302 extend from sheath carriage 104 and catheter 302 may include, as an example, an outer sheath or catheter, an inner catheter, and a guidewire. Sheath carriage 104 is rotatable about axis 128 such that a yaw angle 304 can be imparted to catheter 302. Further, each carriage 104, 106 may have a lift 306 imparted thereto as well, to cause a vertical motion and better position catheter 302 during operation, and to adjust to variation in patient thickness. In addition, leader carriage 106 may also be rotatable about an axis 308 such that a yaw angle 310 may be imparted thereto as well, also to reduce the propensity for catheter 302 to buckle during operation.

The sheath carriage 104 and leader carriage 106 (or pods) may contain an articulation mechanism for steering the pullwires of a catheter (not shown) and a manipulation mechanism for inserting, retracting and rolling an elongate member. The articulation mechanism typically involves 3 or 4 pulleys in the splayer of the catheter attaching to corresponding output shafts in the carriage, the output shaft being driven by motor within the pod. The steering wires running through the wall of the catheter are wrapped around the pulleys as articulation is commanded, resulting in bending of the catheter tip. The manipulation mechanism on the sheath carriage 314 is shown as a pair of feed rollers 318. The manipulation mechanism on the leader carriage is shown as a gripping pad 320. These are exemplary manipulation or active drive mechanisms. It should be understood that any active drive mechanism such as grippers, or chuck mechanism or compressible rollers may be used. In addition, there may be a manipulation mechanism positioned next to the patient access site 132 to constrain and insert, retract, and/or roll sheath 130 into the patient. Active drive mechanism 312 include wheels 316, in one embodiment, that cause sheath 130 to be inserted into a patient, which act in concert with sheath carriage 104 to articulate sheath 130, wherein articulation of the catheter generally refers to steering and selectively positioning the catheter. Similarly, active drive mechanism 314 includes wheels 318, in one embodiment, that cause leader 122 to be inserted into a patient, which act in concert with leader carriage 106 to articulate leader 122, wherein articulation of the catheter generally refers to steering and selectively positioning the catheter. Similarly, active drive mechanism 320, in one embodiment may be attached to carriage 106 to manipulate a guidewire that passes through the center of, and is part of, catheter 302. Active drive mechanism 312 is coupled to rail 120 and will usually not move relative to the patient. Sheath carriage 104, and leader carriage 106 may move relative to 312 and be controlled via workstation 112.

Thus, as shown in FIG. 3, robotic instrument driver 102 includes carriage 104 and its corresponding active drive mechanism 314, carriage 106 and its corresponding active drive mechanism 320 and active drive mechanism 312 that is directly coupled and stationary with respect to rail 120 via a support 322. Support 322 may include a support structure or attachment method to support wheels 316 while allowing wheels 316 to rotate and be driven, to drive sheath 130. Active drive mechanism 314is attached to carriage 104 via its connection or attachment 324.

It is contemplated that active drive mechanism 312 is positioned proximate the patient and is configured to manipulate (insert, retract or roll) sheath 130 into or out of the patient. Carriage 104 is moveable with respect to rail 120 and, hence, with respect to active drive mechanism 312. Active drive mechanism 314 is therefore also moveable with respect to rail 120 and with respect to carriage 106 as well. Carriages 104 and 106 are therefore moveable independent from one another.

It is contemplated according to one example, that catheter assembly 102 does not include carriage 106. It is also contemplated according to another example, that catheter assembly 102 does not include carriage 106 or drive mechanism 318. That is, assembly 102 may be a robotic instrument driver 102 for driving one or more elongate members that includes a first carriage 312 that is positionable to or on bed 110 for inserting, retracting or roll a sheath 130 into or out of a patient. Robotic instrument driver 102 also includes a second carriage such as carriage 104that is positionable proximate to or on bed 110 that is configured to articulate sheath 130, wherein the second carriage 104 is movable independent from the first 312. The second carriage 104 is configured for inserting, retracting or rolling a second elongate member such as an inner catheter, which is articulable from a third carriage, such as carriage 106. Further, third carriage 106 is configured in another example to insert, retract or roll a third elongate member that may be, for instance, a guidewire.

FIG. 4 illustrates an exemplary anti-buckling mechanism that may be incorporated, to reduce the propensity for catheter 302 to buckle during operation, and in lieu of mechanisms 312, 316. Referring to FIG. 4, a scissors-like mechanism may be placed onto catheter 302. The scissors-like mechanism may be a collapsible passive mechanism fabricated from, for instance, plastic or metal, and of such a mass that the catheter extends therethrough with a scissors-action. The mechanism may be positioned between sheath carriage 104 and the patient access site 132 as mechanism 400, and/or between carriages 104, 106 as mechanism 402.

Thus, in general, system 100 includes catheter insertion system 102 having carriages 104, 106. Carriages 104, 106 may otherwise be referred to as lightweight pods that are separately and independently positionable with respect to one another. As such, system 102 avoids using an SUJ and the masses or pods are lightweight, reducing the overall mass of system 100. Carriages 104, 106 are scalable in that they can be sized according to further system catheter needs that may develop over time. Carriages 104, 106 have a low profile and a low height (compared to systems having an SUJ), thus reducing the propensity to interfere with other system equipment. Operation of carriages 104, 106 may also allow for full fluoroscopic image run-off on lower extremity cases, and their operation is not sensitive to different catheter lengths. Further, additional pod/rail combinations could be included within system 100. That is, one or more additional catheter control systems could be placed onto the bed to support further catheter procedures (for instance, a second set of pods on a rail could be included on the bed and on the opposite side of the patient, and perhaps at a different axial location, than that shown in FIGS. 1 and 2). Further, carriages or pods 104, 106 can be easily detachable, supporting a clean and simple method for changing out system components between or during catheterization procedures. The pods and rails shown are aligned to the access site in the femoral artery of the patient. It should be understood that the pods and rails can be set up toward the head of the bed for access sites in the brachial, carotid or auxiliary arteries.

The disclosed bedside system can be very lightweight and provide simpler mechanics for the operating mechanisms. Also, it effectively minimizes wasted catheter length. The disclosed system is a scalable design allowing for the addition of any number of pods for various other manipulators for other tools if desired. Thus, splayers and their actuating motors may be mounted in pods, according to one embodiment. As described, each carrier or pod can have Z axis (up and down) and yaw adjustment, whether manual or robotic. The adjustments can be used to alter the insertion angle of the catheter into the patient. In the disclosed system, the pods may also be mounted to motorized bedside rails providing actuation in the insert/retract directions, as well. There is also no need for setup arms, and interference with C-arm movement is reduced or eliminated. Also, pods could be easily added to the rail making the system very scalable for other system configurations. According to one option, pods are swappable such that one pod that is designed to carry a catheter for example can be swapped with another pod that is designed to carry a tool such as a motorized scalpel, grasper, ablation catheter, etc. In this manner, pods can be swapped mid-procedure depending on which surgical tools are desired during a given procedure.

In some embodiments, the pods contain motors and encoders within the pod to drive operation. A y-axis motor can include a pinion or capstan to interface with the rail via a rack or mechanical cable, respectively. A z-axis motor can connect to a leadscrew, to drive one or multiple stages, to raise and telescope as required. Other z-axis concepts can include a scissor mechanism for extended vertical range. The yaw axis motor can connect to a belt and pulley or gears to rotate the pod. Rotational backlash can be minimized by a miniature harmonic drive gearbox at the motor output. The pod height is determined, in one example, from the table top to the top of the thinnest person's leg, mattress included. The height, in other words, includes the volume below the cantilevered deck.

The rail may include a slide or track, a rack or mechanical cables, and electrical cable harnesses for each pod. The rail can be deployable in one embodiment, meaning it is stowed at the back of the bed and slides into position before use. An alternative is to have a very long rail reach from the end of the bed to the patient's target. The rail can also have a lateral axis to provide patient lateral adjustment and to slide to each side of the table.

The y-axis (up down), z-axis (along the patient), and yaw axis are servo controlled, in one embodiment. In this example, manual set-up is via a pendant or button mounted control. This means that yaw, insertion, and height may be adjusted relative to the target prior to driving. Pods may move in unison vertically. Synchronous pod motion may be used to insert and retract the catheter. The pods may also yaw on a horizontal trajectory while the catheter is inserted and retracted. If inserting and retracting on a fixed pitched angle, say 10°, height may be synchronized as well, resulting in a diving trajectory.

One challenge often experienced with robotically controlled surgical systems is alignment of carriage 104 with the access site of the patient, especially as it approaches the patient. To address misalignment concerns, typically the operator manually maneuvers the carriage 104 (without the sheath 130 attached) into a “fully inserted” position, whereby a nose of the instrument driver 102 is aligned and in close proximity to the access site. The operator would then initiate a “set site” position to effectively teach the carriage 104 the “fully inserted” position. The carriage 104 would then be retracted and the sheath 130 installed. Once installed, the carriage 104 could then be operated to insert the sheath 130 to the installed position. As may be appreciated, the workflow for this procedure is burdensome and time consuming.

To address the above issues, one or more sensors 500 may be attached to the instrument driver 102. This present disclosure contemplates that a variety of sensors 500 may be employed. Such sensors 500 include, but are not limited to a camera, a stereo camera, a range finder, an inclinometer, and a laser beam. These various sensors 500 may be used individually or in combination with one another.

With respect to use of a camera as sensor 500, in one exemplary arrangement, the camera may be mounted on the instrument driver 102 in any suitable location. For embodiments that include a setup joint SUJ, the camera may alternatively be mounted to the SUJ. In one exemplary configuration, the camera is mounted on the nose 502 of the instrument driver 102. The camera would provide a video feed to the workstation 112 to allow the surgeon to visually monitor the access site as the instrument driver 102 approaches the access site. In one exemplary configuration, the video feed could be displayed as a sub-window on the workstation 112 monitor. In this manner, the surgeon would be able to monitor the surgical site, as well as monitor any potential binding of an anti-buckling device, movement or loosing of a stabilizer, and any issues at the access site.

A stereo camera could be coupled with the visual camera. The stereo camera is configured to provide distance information to various points in the image.

Similar to the stereo camera, a range finder may also be employed. The range finder may be used in isolation to measure distance to the access site (for example to prevent collisions with the patient) or in conjunction with a camera image to infer depth of one of several points in the image. The range finder may utilize laser, ultrasonic, or other technology.

The inclinometer would directly measure a pitch angle of the instrument driver 102, thereby allowing adjustments to the instrument driver 102 to align with the access site.

A laser beam may be used to project a simple pointing vector off the nose 502 of the instrument driver 102. Alternatively, the laser may be used to project a reference point onto the camera image. In one exemplary configuration, if the laser and camera are not collocated, then the location of the reference point in the image may be used to infer depth.

In another exemplary configuration, an automated environmental feedback mechanism may be employed in lieu of a sensor. The automated environmental feedback mechanism utilizes a beam of known speed, for example light. To set an insertion site trajectory the beam, for example in the form of a pulsating LED, would be emitted from the front of the instrument driver 102 to a reflective target on a patient patch. An array of areas for providing a return reading would be positioned on the instrument driver 102. Distance from the front of the patient may be determined by calculating the time for a signal return. Angle may also be geometrically determined by the point of return. These data points may be then be used to electronically change the angle of the instrument driver 102 or carriage 104, as well as determine if the instrument driver 102 or carriage 104 should stop a forward or insertion movement. In one exemplary arrangement, the placement of spaced LEDs around the perimeter of the instrument driver 102 would permit use of algorithms by a computer system operatively connected to the workstation 112 and the instrument driver 102 would permit the location of the instrument driver 102 to be determined relative to other pieces of equipment in the surgical suite.

While described in the context of using an LED as the beam, it is understood that any beam having a known speed and refractive qualities (i.e., the ability to reflect from the patient or a suitable patch as opposed to being absorbed or passing through) may be used. Further examples include laser beams and radar.

It will be appreciated that the aforementioned method and devices may be modified to have some components and steps removed, or may have additional components and steps added, all of which are deemed to be within the spirit of the present disclosure. Even though the present disclosure has been described in detail with reference to specific embodiments, it will be appreciated that the various modifications and changes can be made to these embodiments without departing from the scope of the present disclosure as set forth in the claims. The specification and the drawings are to be regarded as an illustrative thought instead of merely restrictive thought. 

1.-20. (canceled)
 21. A robotic instrument driver, comprising: a first pod comprising a first articulation mechanism configured to articulate one or more steering wires in a first elongate member, the first pod further comprising a first active drive mechanism fixed relative to the first articulation mechanism, the first active drive mechanism configured to insert or retract a second elongate member with respect to the first elongate member; and a second pod comprising a second articulation mechanism configured to articulate one or more steering wires in the second elongate member, and further comprising a second active drive mechanism fixed relative to the second articulation mechanism and configured to insert or retract a third elongate member with respect to the second elongate member, wherein the first and second pod are each configured to be movable vertically and rotatable about a yaw axis.
 22. The robotic instrument driver of claim 21, wherein the first active drive mechanism is of a type that is different from the second active drive mechanism.
 23. The robotic instrument driver of claim 21, further comprising a third active drive mechanism, wherein the third active drive mechanism is configured to insert or retract the first elongate member.
 24. The robotic instrument driver of claim 21, wherein the yaw axis is approximately orthogonal to an advancement axis along which at least the first pod is moveable.
 25. The robotic instrument driver of claim 21, wherein the first pod and the second pod are both positioned on a rail, and the rail is attached to a bed.
 26. The robotic instrument driver of claim 21 further comprising an anti-buckling device placed on or around the first elongate member.
 27. The robotic instrument driver of claim 21, further comprising a third active drive mechanism, wherein the third active drive mechanism is configured to insert or retract the first elongate member.
 28. The robotic instrument driver of claim 21, wherein the first and second pods are configured to be rotatable to align at least the first elongate member with an access site of a patient.
 29. The robotic instrument driver of claim 21, wherein the first and second pods are configured to be vertically and rotatably adjustable to optimize the insertion angle of the first elongate member into a patient.
 30. The robotic instrument driver of claim 21, wherein the first and second pods are configured to be moveable vertically or rotatable about the yaw axis in unison.
 31. The robotic instrument driver of claim 21, wherein the second pod is movable independently from the first pod.
 32. A system, comprising: a first carriage comprising a first manipulation mechanism configured to advance or retract a second elongate member relative to a first elongate member; a second carriage comprising a second manipulation mechanism configured to advance or retract a third elongate member relative to the second elongate member, wherein the first carriage and second carriage are each configured to be movable vertically and rotatable about a yaw axis.
 33. The robotic instrument driver of claim 31, wherein the first manipulation mechanism is of a type that is different from the second manipulation mechanism.
 34. The robotic instrument driver of claim 31, further comprising a third manipulation mechanism, wherein the third manipulation mechanism is configured to insert or retract the first elongate member.
 35. The robotic instrument driver of claim 31, wherein the yaw axis is approximately orthogonal to an advancement axis along which at least the first carriage is moveable.
 36. The robotic instrument driver of claim 31, wherein the first carriage and the second carriage are both positioned on a rail, and the rail is attached to a bed.
 37. The robotic instrument driver of claim 31, further comprising an anti-buckling device placed on or around the first elongate member.
 38. The robotic instrument driver of claim 31, further comprising a third manipulation mechanism, wherein the third manipulation mechanism is configured to insert or retract the first elongate member.
 39. The robotic instrument driver of claim 31, wherein the first and second carriages are configured to be rotatable to align the first elongate member with an access site of a patient.
 40. The robotic instrument driver of claim 31, wherein the first and second carriages are configured to be vertically and rotatably adjustable to optimize the insertion angle of the first elongate member into a patient.
 41. The robotic instrument driver of claim 31, wherein the first and second carriages are configured to be movable vertically or rotatable about a yaw axis in unison.
 42. The robotic instrument driver of claim 31, wherein the second carriage is movable independently from the first carriage.
 43. A method, comprising: articulating, via a first articulation mechanism of a first pod, one or more steering wires in a first elongate member, the first pod further comprising a first active drive mechanism fixed relative to the first articulation mechanism, the first active drive mechanism configured to insert or retract a second elongate member with respect to the first elongate member; articulating, via a second articulation mechanism of a second pod, one or more steering wires in the second elongate member, the second pod further comprising a second active drive mechanism fixed relative to the second articulation mechanism and configured to insert or retract a third elongate member with respect to the second elongate member; and moving the second pod independently from the first pod, wherein the first and second pod are each configured to be movable vertically and rotatable to a yaw angle. 